Skill using the American Psychiatric Association's (2000)
Diagnostic and Statistical Manual of Mental Disorders, Text Revision is
essential for the increased professional credibility, career
marketability, and third-party reimbursement of professional counselors.
This article focuses on how to improve counselors' skill with
DSM-IV-TR, by providing definitions, empirical demonstrations, and
strategies for reducing three forms of bias that can lead to
misdiagnosis.

**********

Many counselor educators see greater diagnostic skill with the
fourth edition of the Diagnostic and Statistical Manual of the American
Psychiatric Association, Text Revised (American Psychiatric Association,
2000) as essential for enhanced professional credibility, career
marketability, and third-party reimbursement (Fong, 1990, 1993; Foos,
Ottens, & Hill, 1991; Geroski, Rogers, & Breen, 1997; Hohenshil,
1993, 1996). Most counselor education literature on the DSM has been
focused on instructional approaches, clinical applications, and
reconciliation with the traditional counseling focus on normal
development (Hershenson, 1992, 1993; Hershenson & Strein, 1991; Ivey
& Ivey, 1998). Along with learning about the DSM, counselors also
need to learn how to achieve skill in its use.

Achieving skill with the DSM means learning how to diagnose
accurately and reduce diagnostic inaccuracy or misdiagnosis (Hohenshil,
1993; Seligman, 1996). Reducing diagnostic bias is one way to reduce
misdiagnosis (Cook, Warnke, & Dupuy, 1993; Furlong & Hayden,
1993). Diagnostic bias is defined by Sinecore-Guinn (1995) as an
"error in judgment that counselors make when they collect and
interpret information" (p. 18), and by Widiger and Spitzer (1991)
as "a differential prevalence of either false-positive diagnoses
... and/or false-negative diagnoses" (p. 3). Greater skill with the
DSM requires that counselors learn ways of overcoming diagnostic bias.

Bias is defined statistically as measurement error (Mertens, 1998).
Widiger and Sptizer (1991) used a statistical definition of diagnostic
bias in suggesting it is "deviation from an expected value"
(p. 3). For instance, in 100 coin tosses, bias is expected if the number
of heads or tails greatly exceeds a 50-50 ratio, the expected value.
Widiger and Spitzer identified sampling, assessment, and criterion bias
as risks to accurate diagnosis. The purpose of this article is to
define, demonstrate, and discuss ways of reducing sampling, assessment,
and criterion bias. First, definitions are presented of each form of
diagnostic bias. Second, empirical demonstrations are provided of each
form of diagnostic bias. A final section lists ways of reducing each of
these forms of diagnostic bias, and implications for counselor training,
research, and practice.

DIAGNOSTIC SAMPLING BIAS

Definition

Diagnostic sampling bias occurs when there are significant
differences between a particular diagnostic sample and the population it
is taken to represent (Garb, 1998; Gilovich, 1991). An example of
diagnostic sampling bias is drawing conclusions about the gender of
individuals with Post-Traumatic Stress Disorder (PTSD) on the basis of a
sample taken from a veteran's hospital (Widiger & Spitzer,
1991). Because of the disproportionate number of men in that setting,
conclusions about the gender of those with PTSD will be biased.

Demonstrations of Diagnostic Sampling Bias

DeGrandpre (1999) demonstrated diagnostic sampling bias in an
examination of the ability of physicians to diagnose Attention Deficit
Hyperactivity Disorder (ADHD) solely from observation of children in
their offices. His results indicated that more than three of four
children described as hyperactive by parents and teachers showed
"exemplary behavior and no sign of hyperactivity in the
[doctor's] office" (p. 133). This demonstrates how a
non-representative sample of observations (i. e., only in a
physician's office) can lead to misdiagnosis.

Researchers also demonstrated sampling bias in another study
comparing clinical and community samples of children with a diagnosis of
ADHD (Sharp, Walter, & Marsh, 1999). In referred samples, four to
nine times more boys than girls received an ADHD diagnosis. However, in
community samples, ratios as low as two to one have been found. This
gender discrepancy between clinical and community samples raises
questions about the representativeness of many clinical samples.

Wilke (1994) also demonstrated diagnostic sampling bias in research
with women and alcohol abuse. She observed that, because the most
research on alcohol abuse and treatment has focused on men, conclusions
about treatment are inappropriate when applied to women. Because women
with alcohol problems are less likely than men to drink in public, drink
with others, become violent or aggressive, or to come into contact with
the law, many of their alcohol problems go undiagnosed and untreated.
This research demonstrates how over-generalizing from one group to
another can lead to misdiagnosis.

The dramatic rise in the number of Multiple Personality Disorder (MPD) diagnoses made during the 1970s in the United States can also be
seen as a demonstration of diagnostic sampling bias (Hacking, 1995;
Ofshe & Watters, 1994; Spanos, 1994). The increased number of MPD
diagnoses given to individuals in the United States did not occur
elsewhere (Kutchins & Kirk, 1997). Therefore, some observers have
concluded that the increase in the United States constituted a biased
sample instead of reflecting an actual increase in the disorder
(Hacking; Ofshe & Watters).

DIAGNOSTIC ASSESSMENT BIAS

Definition

Diagnostic assessment bias occurs when flaws in gathering or
processing clinical information lead to misdiagnosis (Dawes, 2001;
Falvey, 1992; Gambrill, 1990; Rabinowitz & Efron, 1997). Diagnosing
someone solely on the basis of a previous clinician's assessment is
an example of diagnostic assessment bias. The lack of a timely and
comprehensive assessment can lead to diagnostic assessment bias and thus
misdiagnosis.

Demonstration of Diagnostic Assessment Bias

One issue in the diagnostic assessment bias literature is errors in
applying the diagnostic criteria (Rabinowitz & Efron, 1997). In one
demonstration of this bias, Morey and Ochoa (1989) asked 291
psychiatrists and psychologists to complete a symptom checklist for a
client whom they had diagnosed with a personality disorder. When the
checklists were later correlated with the DSM criteria, nearly three of
four clinicians had made mistakes in applying the diagnostic criteria.
Kappa coefficients of agreement between clinicians' checklists and
the DSM criteria varied from 0.09 to .59, indicating a poor-to-modest
level of agreement (Babbe, 1998). These results demonstrate the
pervasiveness of errors in applying diagnostic criteria.

Errors in applying the DSM criteria were also reported by Davis,
Blashfield, and McElroy (1993). They asked 42 psychologists and 17
psychiatrists to read and diagnose case reports containing different
combinations of the DSM-III-R criteria for Narcissistic Personality
Disorder (NPD; APA, 1987). They found that 94% of the clinicians made
mistakes applying the diagnostic criteria, and nearly one out of four
clinicians made a diagnosis of NPD even if fewer than half the DSM
criteria were met.

Rubinson, Asnis, Harkavy, and Freidman (1988) found clinicians
making more mistakes of omission than of commission in applying the DSM
criteria. Researchers sent 113 questionnaires to a random sample of
clinicians asking them what criteria they used to make a diagnosis of
Major Depression. The 54 questionnaires returned indicated that
clinicians' most often erred by failing to use all the diagnostic
criteria in their diagnostic decision making.

The fallibility of supplemental diagnostic assessment methods
(e.g., psychometric instruments, structured interviews, psychological
reports) is another issue in the literature on diagnostic assessment
bias (Gambrill, 1990; Rabinowitz & Efron, 1997). Kosten and
Rounsaville (1992) demonstrated this fallibility by showing that
diagnoses made by clinicians using structured and semi-structured
interviews often differed substantially from those made by panels of
expert clinicians using more thorough information from medical records
and patient and family interviews. Similar results have also been found
when using objective or projective psychological test data to formulate
diagnoses (Garb, 1998).

The fallibility of supplemental assessment methods was also
demonstrated in a study that compared typical clinical approaches with
several supplemental assessment methods in a group of adolescent
psychiatric inpatients (Prinstein, Nock, & Spirito, 2001). Prinstein
et al. found agreement among the various assessment methods was low to
moderate (K = 0.21-0.49), and concluded that accurate assessment
requires multiple methods that take into consideration the limitations
of each.

Another issue in the diagnostic assessment bias literature is human
information processing errors (Dawes, 2001; Falvey, 1992; Gambrill,
1990; Piattelli-Palmarini, 1994; Rabinowitz & Efron, 1997; Spengler,
2000; Spengler & Stromer, 1994; Turk & Salovey, 1988). Several
of these errors have been identified. This discussion will focus on the
four information-processing errors most likely to lead to assessment
bias and misdiagnosis:

* Stereotyping

* Data availability and vividness

* Self-confirmatory bias

* Self-fulfilling prophecy

Stereotyping. Stereotyping refers to "special types of
cognitive structures involved in categorizing individuals or social
targets" (Abreu, 2001, p. 493). Stereotyping distorts the normal
information-processing strategy of making judgments on the basis of the
multidimensional resemblance of a case to an ideal example or prototype
(Falvey, 1992; Garb, 1998; Gilovich, 1991; Lakoff, 1987;Turk &
Salovey, 1988). In stereotyping, judgments are made on the basis of only
one or a limited number of common features. Because of their
incompleteness and inflexibility, stereotypes often lead to error, and
clinical stereotypes often lead to misdiagnosis (Abreu; Falvey;
Gambrill, 1990; Garb; Rabinowitz & Efron, 1997; Turk & Salovey).

One demonstration of how stereotyping can lead to misdiagnosis
comes from a study in which 290 African-American and White psychiatrists
of both genders diagnosed case summaries. The results indicated that
"all four groups of psychiatrists seem to be influenced by the
clients' sex and race" (Loring & Powell, 1988, p. 17). A
similar study by Landrine (1989) reached the same conclusion. In her
study of two proposed diagnoses, she found Sadistic Personality Disorder more often diagnosed in males, and Self Defeating Personality Disorder
more often diagnosed in females.

Another demonstration of stereotyping leading to misdiagnosis came
from a study in which 67 psychologists and psychology interns first made
diagnoses of case histories, and then rated how closely those case
histories were to a typical person showing symptoms consistent with that
particular diagnosis (Garb, 1998). Participants' ratings indicated
they believed the case histories were quite typical of those receiving a
particular diagnosis; however, the correlations between their diagnoses
and their ratings and the DSM criteria were low. This result suggests
they had made their diagnostic judgments on the basis of clinical
stereotypes rather than the DSM criteria.

Data availability and vividness. Data availability and vividness
refers to categorizing something on the basis of its familiarity, ease
of recall, or salience (Falvey, 1992; Piattelli-Palmarini, 1994;
Spengler, 2000; Turk & Salovey, 1988). One demonstration of this
information-processing error used a questionnaire to ask clinicians how
they made a diagnosis of depression (Rubinson et al., 1988). The
clinicians' reports indicated that they had used a subset of the
DSM criteria they found most familiar, salient, or easiest to recall in
formulating their diagnoses. A study by Robertson and Fitzgerald (1990)
found similar results. They randomly assigned 47 counselors to view
different videos of an actor portraying a depressed male. The only
difference in the videos was the client's occupational and family
role, which was categorized as either traditional or nontraditional. The
results indicated counselors based their diagnostic judgments more on
the available and vivid family and occupational role than on the less
available and vivid signs and symptoms of a specific disorder.

A focus on data availability and vividness as a basis for
diagnostic judgment can also lead to an under-emphasis on co-existing,
but less available and vivid disorders (Spengler, 2000; Spengler &
Stromer, 1994). This underemphasis on possible co-morbidity has been
referred to as "diagnostic overshadowing" (Spengler &
Stromer, p. 8) and occurs independent of practitioners' experience,
expertise, theoretical proclivity or nature of the client's
problems (Spengler & Stromer).

Data availability and vividness also explains how the phenomenon of
Primacy Effects can contribute to misdiagnosis (Lake, 2000). Primacy
Effects refer to how people are most influenced by the first information
they receive about something (Gilovich, 1991). Sharps, Price, and Bence
(1996) offer an empirical demonstration of this effect. They
hypothesized that pictorial information would be less affected by the
primacy effect than verbal or auditory information. To test their
hypothesis, they presented 40 photos, sounds, and words to 70
participants. The results confirmed their hypothesis: Pictorial
information was significantly less affected by the primacy effect than
either sounds or words. However, given the large part played by words in
diagnostic practice (there are few pictures in the DSM), this study
demonstrates how primacy effects can contribute to misdiagnosis.
Finally, basing diagnostic decisions on data availability and vividness
can also lead to the neglect of base-rate data, or what is typical in a
given population. Neglect of base-rate data in favor of other data such
as personal clinical experience has long been associated with less
accurate clinical judgments, including misdiagnosis (Falvey, 1992;
Rabinowitz & Efron, 1997; Spengler, 2000).

Self-confirmatory bias. This error refers to categorizing something
by focusing only on confirmatory information (Stromer, Boas, &
Abadie, 1996). This error is demonstrated by counseling and counseling
psychology students who first saw a video of an initial counseling
session and then were asked to provide a list of questions they wanted
to ask the client and explanations for their questions. The questions
were then coded as to whether they sought confirmatory, disconfirmatory,
or neutral client information. The results indicated 64% of the
questions sought confirmatory information, 21% sought disconfirmatory
information, and 15% sought neutral information (Haverkamp, 1993). A
study by Pfeiffer, Whelan, and Martin (2000) obtained similar results.

Self-fulfilling prophecy. This error refers to acting on an
expectation in a way that confirms it (Garb, 1998; Gilovich, 1991).
Rosenhan (1973) provides probably the most notable demonstration of
self-fulfilling prophecy connected to psychiatric diagnosis. He had 12
research confederates gain admission to psychiatric hospitals by
complaining of auditory hallucinations. The 12 gave truthful answers to
all questions except their name, occupation, and place of employment.
Once admitted, none of the confederates complained of further symptoms.
Nonetheless, all 12 were misdiagnosed as suffering from serious
psychiatric disorder at discharge. Rosenhan demonstrates how a
self-fulfilling prophecy can lead to misdiagnosis by showing how the
hospital staff acted to confirm their expectation that individuals
admitted to psychiatric hospitals have a diagnosable disorder by
diagnosing them even in the face of information to the contrary.

Kyunghee (1996) also demonstrated self-fulfilling prophecy by
showing how some teachers' views of intelligence influenced their
predictions of academic performance. Teachers first took a test to
identify whether they saw intelligence as static or as malleable. The
teachers were then told about a student referred for counseling because
of adjustment problems, were asked to grade that student's math
assignment, and then to predict how well that student would do
academically. The results indicated that teachers with a static view of
intelligence offered biased predictions that confirmed their original
views of intelligence.

DIAGNOSTIC CRITERION BIAS

Definition

Diagnostic criterion bias occurs when diagnostic criteria are
"more valid for one group than for another" (Garb, 1998, p.
233). Making diagnostic judgments based on a White-male standard of
adjustment has been viewed as diagnostic criterion bias (Cook et al.,
1993; Russell, 1994; Tavris, 1992). Because of the greater social
challenges women and minorities face, using a White-male standard of
adjustment is seen as prejudicial, an example of diagnostic criterion
bias (Caplan, 1995; Russell; Tavris; Wilke, 1994). For example, Cook et
al. refer to the "male-based norms" (p. 312) used as a basis
for determining mental health in the DSM, and Caplan rejected the DSM
diagnosis of "Premenstrual Dysphoric Disorder" (APA, 1994, p.
717), because of its bias against women.

The issue of homosexuality in the DSM is another example of
diagnostic criterion bias (Caplan, 1995; Kirk & Kutchins, 1992;
Kutchins & Kirk, 1997; Tavris, 1992). Homosexuality was included as
one of the Sexual Deviations in the first edition of the DSM, and listed
as a separate diagnosis in DSM-H (APA, 1952). In the 12 years between
publication of the DSM-II and the DSM-III, a debate occurred over
whether homosexuality was a diagnosable condition (Caplan; Kutchins
& Kirk). Subsequently, the DSM-III included only homosexuality that
troubled the individual (Ego-Dystonic Homosexuality) as a diagnosis, and
7 years later the diagnosis was eliminated altogether (APA, 1980; APA,
1987; Kutchins & Kirk). The inclusion and elimination of
homosexuality as a diagnosis in the DSM has been in large measure
attributed to awareness of the criterion bias inherent in the diagnosis
(Kutchins & Kirk; Tavris).

Pollack, Martin, and Langebucher (2000) also demonstrated
diagnostic criterion bias when they examined the correspondence among
diagnostic criteria for alcohol use disorders (AUDs) in a group of
teenagers across three editions of the DSM. More than 400 youth from
mental health clinics and the community participated. AUDs were
determined through a structured interview designed for the DSM and
altered to reflect each successive edition. The results indicated
moderate to good correspondence in the diagnostic criteria for alcohol
dependence, and poor correspondence on the diagnostic criteria for
alcohol abuse. Pollack et al. concluded that there remains a lack of
consensus about the diagnostic criteria for alcohol disorders in the
DSM. Their findings demonstrate how shifting diagnostic criteria can
lead to misdiagnosis.

REDUCING MISDIAGNOSIS DUE TO DIAGNOSTIC BIAS

Strategies for Reducing Diagnostic Sampling Bias

Reducing misdiagnosis due to diagnostic sampling bias requires
counselors to consider how insufficient, nonrepresentative data can lead
to misdiagnosis. Counselors can do the following to reduce diagnostic
sampling bias:

2. Pay attention to how your work setting may bias your diagnostic
judgments.

3. Focus on the atypical aspects of a case because doing so may
help you detect ways it is not typical of a particular diagnosis (Morrow
& Deidan, 1992).

Reducing Misdiagnosis due to Diagnostic Assessment Bias

Reducing misdiagnosis due to diagnostic assessment bias requires
counselors to develop ways of assuring proper collection and processing
of clinical information. Counselors can do the following to minimize
diagnostic assessment bias:

1. Adhere with all the DSM diagnostic criteria, and keep current
about revisions.

2. Consider the possibility of co-morbidity as a guard against the
diagnostic overshadowing bias (Spengler & Stromer, 1994).

3. Take the time to consider different diagnostic possibilities.
Recent research indicates that delaying diagnostic judgments improves
their accuracy and reduces the influence of primacy effects (Hill &
Ridley, 2001; Morrow & Deidan, 1992).

4. Use a sign and symptom checklist as part of a standard
assessment to assure that all the DSM criteria for a particular disorder
have been considered.

5. Complete a "balance sheet" (Arnoult & Anderson,
1988, p. 209) of the pros and cons of a particular diagnosis to guard
against confirmatory bias.

7. Write down your expectations about clients to make them explicit
and thereby reduce the likelihood of self-fulfilling prophecies (Morrow
& Deidan, 1992).

Reducing Diagnostic Criterion bias

Reducing diagnostic criterion bias requires counselors to keep in
mind the strengths and limitations of the DSM and the diagnostic
process. Despite its flaws, successive editions of the DSM have achieved
increased increments in reliability and validity of many diagnostic
categories (Nathan & Langenbucher, 1999). In order to reduce
misdiagnosis due to diagnostic criterion bias counselors can do the
following:

1. Keep in mind the role social factors play in the development of
psychiatric diagnostic criteria and be aware of how the DSM favors some
groups over others (Kirk & Kutchins, 1992; Kutchins & Kirk,
1997).

3. Take advantage of all available DSM training, with a particular
emphasis on how to use the DSM in a way sensitive to the needs of a
diverse, multicultural society (Aderibigbe & Pandurangi, 1995;
Rogler, 1992).

IMPLICATIONS FOR COUNSELOR TRAINING AND PROFESSIONAL PRACTICE

There are several implications in this article for counselor
training and professional practice. First, training in key
social-science concepts should precede DSM training in counselor
curricula, because understanding key social-science concepts promotes
critical inquiry (Arnoult & Anderson, 1988; Dawes, 2001; Lehman,
Lempert, & Nisbett, 1988). Counseling students should understand at
minimum the concepts of representative sampling, reliability and
validity, correlation, and the logic of base-rates before taking
coursework in the DSM.

Second, counselors must have in-depth information about the current
scientific standing of the DSM (Nathan & Langenbucher, 1999). This
information is essential for counselors to make informed decisions about
its use in their professional practice. Being ill informed about the
scientific status of the DSM invites either overconfidence or cynicism
and corresponding risk of misdiagnosis (Rentoul, 1995).

Third, counselors must be able to distinguish sound from unsound assessment instruments and practices (Falvey, 1992; Widiger &
Spitzer, 1991). They must understand the importance of a comprehensive
assessment and how to reach rational conclusions from data (Dawes, 2001;
Gambrill, 1990; Garb, 1998; Rabinowitz & Efron, 1997). Counselors
should also be cautious about the predictive power of tests and other
assessment instruments and should be taught different assessment methods
for different professional settings and circumstances (Gambrill; Garb).

Fourth, counselor education coursework should include a detailed
review of the human information processing errors related to clinical
practice (Rabinowitz & Efron, 1997; Rentoul, 1995). That review
should include the four errors identified in this article and any
cognitive errors future research identifies as relevant to diagnostic
decision making.

Fifth, coursework in the DSM should include both "conventional
and sociohistorical" (Sampson, 1991, p. 3) perspectives on
psychiatric diagnosis (Ivey & Ivey, 1999; Rentoul, 1995). Whereas in
the former, diagnostic categories are viewed as representing objective
entities, in the latter they are viewed as socially constructed (Gergen,
1994; Leeds-Hurwitz, 1995). These two perspectives can provide a
conceptual framework for helping students appreciate the social and
scientific aspects of the DSM and help produce a deeper, more
sophisticated understanding of the DSM and the diagnostic process
(Rentoul).

Practicing counselors will benefit from creating a work environment
where careful use of the DSM is supported (Gambrill, 1990; Turk &
Salovey, 1988). They will also benefit from implementing a number of
practices, including being alert for the three forms of bias discussed
here, and any preconceptions they bring to their diagnostic practice
(Rabinowitz & Efron, 1997). Creating opportunities to receive
feedback from peers on diagnostic decisions is also an important way of
furthering diagnostic skill and practice and of reducing misdiagnosis
(Garb, 1998). Implementing these suggestions should help reduce
misdiagnosis due to diagnostic bias and help enhance professional
counselors' credibility, marketability, and opportunities for
reimbursement.